Monitoring anti-Xa Levels to Optimize Low-Molecular-Weight-Heparin Thromboprophylaxis in High-Risk Hospitalized Patients: A Stratified Meta-Analysis.

It is uncertain whether monitoring or targeting anti-Xa levels is necessary when using low-molecular-weight-heparin (LMWH) to prevent venous thromboembolism (VTE). This stratified meta-analysis assessed whether monitoring trough or peak anti-Xa levels with LMWH dosing would reduce risk of VTE. Twelve non-randomized studies involving 3604 hospitalized patients met the inclusion criteria and were subject to meta-analysis. Eight studies assessed the association between VTE and peak anti-Xa levels (between .2 and .5 IU/ml) and four studies assessed the benefits of targeting the trough anti-Xa levels (>.1 IU/ml). Achieving an adequate peak or trough anti-Xa level was associated with a reduced risk of VTE (random-effects model odds ratio [OR] .52, 95% confidence interval [CI] .34-.77; P = .001, I2 = 30% and P-value for heterogeneity = .171) compared with using a fixed standard dose of LMWH. Targeting the trough level (OR .40, 95%CI 0.22-.75, P = .004) appeared to be more effective than targeting the peak level (OR .62, 95%CI 0.37-1.03, P = .066), although a formal interaction analysis did not confirm they were statistically different (ratio of ORs = 1.52, 95%CI 0.68-3.40; z score = 1.03, P = .306). Targeting a higher anti-Xa level did not appear to increase the risk of bleeding or transfusion (OR 1.20, 95%CI 0.46-3.17, P = .707).

Feasibility of bubble non-invasive positive pressure ventilation, a first-in-human study.

PURPOSE: Infant respiratory distress is  a significant cause of mortality globally. Bubble continuous positive airway pressure (CPAP) is a simple and effective therapy, but sicker infants may require additional support such as non-invasive positive-pressure ventilation (NIPPV). We investigated the feasibility of a simple, low-cost, non-electric bubble NIPPV device. METHODS: In this cross-over feasibility study, seven newborns with moderate respiratory distress (Downes score ≥ 3), weight > 1500 g and gestational age > 32 weeks were randomized to  4 h of treatment with bubble CPAP (5-8 cm H2O) vs. bubble NIPPV (Phigh 8-10 cm H2O/Plow 5-8 cm H2O) followed by 4 h of the alternate treatment. Treatment order (CPAP vs. NIPPV) was randomized. Outcome measures included hourly vital signs, Downes score and O2 saturation. Adverse events including pneumothorax, nasal septal necrosis, necrotizing enterocolitis and death before discharge were also recorded. RESULTS: It took nurses 39 (7.3) s to assemble the bubble NIPPV device. Patients had similar vital signs and Downes scores on both treatments; median (IQR) values on bubble CPAP vs. bubble NIPPV were: heart rate 140 (134.5, 144), 140 (134.5, 144); respiratory rate 70 (56, 80), 65 (58, 82), Downes score 4 (3, 5.75), 4 (3, 5), O2 96 (94, 98), 97 (96, 98). All newborns survived to discharge and there were no adverse events. . CONCLUSIONS: A simple, low-cost, non-electric method of providing NIPPV for newborns with respiratory distress is feasible in limited resource settings. Randomized-controlled trials comparing bubble CPAP and bubble NIPPV are justified.

To Drill or not to Drill: A Turnabout in Endodontic Practices during Corona Virus Disease -2019- A South India Based Study.

Introduction: The emergence of coronavirus disease-2019 (COVID-19) pandemic poses an immense global health challenge. It also had a profound impact on dentistry with all elective treatment grinding to half initially and a slow phased return to normal services. The aim of the article is to provide an insight into the effect of COVID-19 on endodontic treatment. Materials and Methods: A cross-sectional study among endodontists of various southern states of India was conducted from January 1, 2021 to March 31, 2021, using an online questionnaire. A total of 300 dentists who perform endodontic treatment in daily clinical practice were chosen for the survey. The information was coded, entered, and analyzed utilizing SPSS 20.0 version. Results: A total of 263 questionnaires were answered by the selected group. About 92.01% of endodontists have made changes in infection control including modification in their personal protective equipment and duration of the interval between their appointments. A whopping 74.14% of endodontists faced the economic loss of varying degrees due to the pandemic. In general tremendous changes have been occurred in their daily practice following the pandemic. Conclusion: The pandemic's current and enduring consequences on every part of our lives have been a cause of pain and frustration, but it has also highlighted the human spirit's resilience. Ideally, endodontists must be able to select the best arrangements for safely performing their procedures.

Bubble bilevel ventilation facilitates gas exchange in anesthetized rabbits.

BACKGROUND: Bubble continuous positive airway pressure is an established therapy for infants in respiratory distress. In resource-limited settings, few treatment options exist for infants requiring further respiratory support. A bubble bilevel device has been developed to provide nonelectric, time-cycled, pressure-limited respiratory support. We compared the efficacy of bubble bilevel ventilation with conventional mechanical ventilation in sedated rabbits. METHODS: Six adult rabbits under inhaled isoflurane general anesthesia were ventilated by alternating intervals of conventional and bubble bilevel ventilation for three 10-15-min periods. During each period, interval arterial blood gas (ABG) measurements were obtained after at least 10 min on the respective mode of ventilation. RESULTS: The bubble bilevel system was able to deliver the following pressures: 20/7, 15/5, 12/5, 8/5 cm H2O. The estimated differences in arterial blood gas values on bubble bilevel vs. ventilator were as follows (normalized values): pH 7.41 vs. 7.40, pCO2 37.7 vs. 40, pO2 97.6 vs. 80. In addition, the bubble bilevel ventilation delivered consistent pressure waveforms without interruption for over 60 min on two rabbits. CONCLUSION: This study demonstrates promising in vivo results on the efficacy of a novel bubble bilevel device, which may prove useful for infants in respiratory distress. IMPACT: Given the lack of personnel, funds or infrastructure to provide neonatal mechanical ventilation in resource-limited settings, additional low-cost, low-tech treatments are necessary to save infant lives. Bubble bilevel ventilation reliably delivers two levels of airway pressure to anesthetized rabbits resulting in normalization of blood gases comparable to those achieved on a traditional ventilator. If proven effective, simple technologies like this device have the potential to significantly impact neonatal mortality due to respiratory distress globally.

Acceptance of COVID-19 Vaccine among Dental Professionals: A Cross-Sectional Study among Practitioners, Residents, and Students.

INTRODUCTION: The COVID-19 pandemic spread rapidly across the world, prompting governments to impose lengthy restrictions on both movement and trade. While lockdowns reduce the prevalence of COVID-19 disease, they may have a negative impact on the economy and job levels. Dental medicine has been one of the most severely impacted industries during this crisis. Dental professionals are exposed to environments with high levels of occupational hazards, additional risks of viral exposure, and transmission. METHODS: We analyzed 705 anonymous questionnaires filled out by dentists, dental students, and postgraduate students about their willingness to consider a new SARS-CoV-2 vaccine. RESULTS: Our findings show a statistically significant relationship between an individual's unemployment rate and their ability to be immunized with a SARS-CoV-2 vaccine. CONCLUSION: As part of the global vaccination program's alertness, these data may be used to forecast patterns in vaccine adoption or denial depending on economic burden during the COVID-19 pandemic by various industries.

Bench Testing of a Bubble Noninvasive Ventilation Device in an Infant Lung Simulator.

BACKGROUND: Infant respiratory distress remains a significant problem worldwide, leading to more than one million neonatal deaths each year. The cost, maintenance, energy, and personnel required to implement ventilators have proven to be a barrier in many resource-limited settings. To address these barriers, a nonelectric bubble noninvasive positive pressure ventilation (NIV) device was developed. This study aims to benchmark the performance of this bubble NIV device against commercially available ventilators. METHODS: The delivered pressure waveforms and tidal volumes of the bubble NIV device were compared with those of 2 conventional ventilators (ie, Dräger Evita Infinity V500 and Hamilton G5) at the following pressure settings: 8/5, 12/5, and 15/5 cm H2O. To simulate the lung mechanics of an infant in respiratory distress, tests were conducted on the IngMar ASL 5000 Test Lung simulator. Resistance was set at 100 cm H2O/L/s, and compliance was tested at 0.5, 1.0, and 2.0 mL/cm H2O to simulate 3 different patients. RESULTS: The delivered pressure waveforms and compliance curves of the bubble NIV device are similar to those of the Hamilton and Dräger ventilators. The mean ± SD differences between delivered versus set pressure gradient (ie, the difference between the high delivered pressure and the low delivered pressure) for each treatment modality across the various values of compliance were -2 ± 8% for the bubble NIV device, 3 ± 4% for the Dräger ventilator, and 7 ± 10% for the Hamilton ventilator. CONCLUSIONS: The similarity of pressure waveforms and delivered tidal volumes in this simulated clinical scenario suggest that the bubble NIV device may provide comparable efficacy compared with traditional ventilator treatment for a range of patients. This may provide clinicians in resource-limited settings with an additional, simple, nonelectric treatment modality for the management of infant respiratory distress.

The BCPAP Score: Five Questions to Assess the Effectiveness of a Bubble CPAP Circuit.

Respiratory illnesses are a leading cause of infant mortality worldwide. Bubble CPAP is a simple and effective treatment for infants in respiratory distress. Across resource-limited settings, various bubble CPAP setups have been used with widely varying results. Based on fundamental fluid dynamics principles and clinical experience, the BCPAP score has been developed to gauge effectiveness of bubble CPAP delivery in different settings. Five questions addressing Bubbles, Circuit, Prongs, Airway and Pressure allow clinicians to rapidly determine whether they are delivering effective bubble CPAP. This article describes how to calculate a BCPAP score and explains the rationale behind the BCPAP score.

Development and Testing of a Bubble Bi-Level Positive Airway Pressure System.

BACKGROUND: Neonatal respiratory distress results in > 1 million annual deaths worldwide. Bubble CPAP is a simple, effective, and widely used therapy for infants in respiratory distress. In low-resource settings, more advanced respiratory support is limited by cost, technical expertise, and sporadic electricity. We sought to develop a safe, inexpensive, and simple solution to provide further respiratory support for these infants. METHODS: A standard bubble CPAP system was modified to provide 2 levels of positive airway pressure (bi-level positive airway pressure) by attaching a novel device. To demonstrate reliability, the system was run with continuous pressure monitoring on full-term and preterm neonatal mannikins with pressure targets of 8/5 cm H2O and 15/5 cm H2O to simulate 2 different modes of noninvasive ventilation (NIV). RESULTS: At a ventilation rate set between 30 and 45 cycles/min, by adjusting the leak rate of the device, the following mean pressures ± SD were demonstrated: term mannikin low-pressure NIV, 7.9 ± 0.2/5.3 ± 0.2 cm H2O; term mannikin high-pressure NIV, 15.1 ± 0.1/6.1 ± 0.1 cm H2O; preterm mannikin low-pressure NIV, 7.9 ± 0.2/5.3 ± 0.2 cm H2O; preterm mannikin high-pressure NIV, 16.5 ± 0.4/5.1 ± 0.1 cm H2O. CONCLUSIONS: The modified bubble CPAP system reliably provided alternating pressures similar to bi-level positive airway pressure modes of respiratory support in neonatal mannikins. The dual-pressure technology is a simple, single connection add-on that can readily be applied to existing bubble CPAP systems.

A rare complication of laparoscopic surgery.

Gallstone disease is one of the most common problems affecting the digestive tract. Symptomatic patients are advised to undergo laparoscopic cholecystectomy (LC), which is considered the gold standard of care in these patients. LC has clear advantages over traditional surgery such as a shorter hospital stay, an earlier return to work and better patient satisfaction. Despite LC being a common surgical procedure, it is not totally free from complications. These include cardiorespiratory problems, biliary leakage, peritonitis, hemorrhage and superior mesenteric artery (SMA) occlusion. We report an unusual and fatal complication of LC, being SMA thrombosis complicated by multiple intra-abdominal collections, abdominal compartment syndrome, multiorgan failure and septic shock.

Magnetic resonance imaging versus histological assessment for estimation of lesion volume after experimental spinal cord injury. Laboratory investigation.

OBJECT: The purpose of this study was to compare measures of lesion volume obtained by means of 1.5-T MR imaging to those obtained by the Cavalieri method, 6 weeks after experimental spinal cord injury. METHODS: Nine male Wistar rats were subjected to spinal cord injury by clip compression (50 g) at the T-4 level. Six weeks postinjury, the rats were sacrificed, and spinal cords were analyzed ex vivo for lesion volume by means of 1.5-T MR imaging and subsequently, by the Cavalieri method. In the latter method, cords were cut longitudinally in 25-microm sections and stained with solochrome cyanin for myelin. The area of the lesion was determined for each serial section, and the distance-weighted sum of all area measures was then calculated to estimate the total lesion volume. RESULTS: Bland-Altman analysis showed that the 2 methods had an acceptable level of agreement for lesion volume estimation, but the Cavalieri method was prone to an overestimation bias. The MR imaging estimates of lesion volume were greater than the Cavalieri method estimates in 3 spinal cords, but the difference between measures was within 1 standard deviation of perfect agreement in these 3 lesions, and the mean difference between measures was 18.3%. In contrast, in those lesions in which the Cavalieri method yielded larger lesion volumes (5 lesions), the difference between measures was 2 standard deviations away from perfect agreement for 2 animals and the mean difference between measures was 72.4%. CONCLUSIONS: The results illustrate that the overestimation bias of the Cavalieri method is due, in part, to artifacts produced during processing of the spinal cord tissue.

Effects of polyethylene glycol and magnesium sulfate administration on clinically relevant neurological outcomes after spinal cord injury in the rat.

The purpose of this study was to determine the long-term effects of polyethylene glycol (PEG) and magnesium sulfate (MgSO(4)) on clinically relevant motor, sensory, and autonomic outcomes after spinal cord injury (SCI). Rats were injured by clip compression (50 g; T4) and treated 15 min and 6 hr postinjury intravenously (tail vein) with PEG (1 g/kg, 30% w/w in saline; n = 11), MgSO(4) (300 mg/kg; n = 5), PEG + MgSO(4) (n = 6), or saline (n = 10). Behavioral testing lasted for 6 weeks, followed by histological analysis of the spinal cord. Both PEG and MgSO(4) resulted in enhanced locomotor recovery and lower susceptibility to neuropathic pain (mechanical allodynia) compared with saline. At 6 weeks, BBB scores were 7.3 +/- 0.2, 7.7 +/- 0.4, and 6.4 +/- 0.6 in PEG-treated, MgSO(4)-treated, and saline-treated control groups, respectively. Likewise, at 6 weeks PEG-, MgSO(4)-, and saline-treated control animals showed 3.5 +/- 0.4, 2.8 +/- 0.9, and 5.0 +/- 0.5 avoidance responses to at-level touch, respectively. PEG + MgSO(4) improved locomotor recovery and reduced pain but did not provide additional benefit compared with either treatment alone. Neither treatment, nor their combination, attenuated mean arterial pressure (MAP) increases during autonomic dysreflexia. However, saline-treated controls had significantly lower resting MAP than PEG-treated rats and tended to have lower resting MAP than MgSO(4)-treated rats 6 weeks postinjury. MgSO(4) treatment and PEG + MgSO(4) treatment resulted in significant increases in dorsal myelin sparing, and the latter resulted in significant reductions in lesion volume, compared with saline-treated controls. Furthermore, mean lesion volumes correlated negatively with the corresponding mean BBB scores and positively with the corresponding mean pain scores. In conclusion, both PEG and MgSO(4) enhanced long-term clinical outcomes after SCI.

Effects of a novel tripeptide on neurological outcomes after spinal cord injury.

A biologically active tripeptide [phenylalanine glutamate glycine (feG)] derived from the submandibular gland has anti-inflammatory actions. We have shown that intravenous treatment with feG after spinal cord injury decreases the intraspinal infiltration of leukocytes and associated oxidative damage within 72 h after injury. The present study assessed effects of this treatment on chronic neurological outcomes after clip-compression spinal cord injury at the 12th thoracic segment. Locomotor scores of feG-treated rats were significantly higher than those of controls at 7 weeks after spinal cord injury. Treated rats had significantly less hind paw mechanical allodynia than controls at this time. In conclusion, the anti-inflammatory and anti-oxidative actions of feG treatment correlate with improved neurological outcomes after spinal cord injury.